Nora Volkow on Rx opioids, chronic pain and ‘hype’

Nora Volkow on prescription opioids, chronic pain and ‘hype’ – Opioid Watch – Nonprofit News from The Opioid Research Institute – July 2018

Research psychiatrist Nora Volkow, MD—the director of the National Institute on Drug Abuse for the past 15 years—is one of the world’s foremost authorities on addiction. Her pioneering work with brain imaging has changed society’s understanding of the phenomenon.

By showing how addictive drugs alter the brain’s chemistry, she helped prove that addiction was a chronic disease rather than a moral failing.

What follows is part 1 of a two-part interview, which was conducted by email. All links in her answers are to supporting references Volkow provided.  

  • Opioid prescriptions have come down since their peak, yet opioid-related overdoses have continued to rise. Many people write me saying that this proves that prescription opioids play no role in the epidemic, that perhaps they never did, and that the focus on the dangers of prescriptions opioids is “media hype.” What is your view?

Prescription opioid volumes in the US peaked in 2011 and have indeed declined since then by about 29% (See here and here.) It seems reasonable to assume that this downward trend reflects an increased concerted effort (by policy and medical establishments) to address the nation’s opioid overdose epidemic.

epidemiological data show that as widely prescribed opioids became less accessible due to supply side interventions, heroin use skyrocketed.

There can be little doubt that the “flooding” of US communities with opioid prescriptions has facilitated diversion of these medications and caused serious public health consequences

Thus, there is a continuous need for physicians to reconsider the management of chronic non-cancer pain with opioids and to better understand the separate but related effects of opioids on analgesia, overdose, and addiction.

However, expecting that declines in rates of prescribed opioids could, by themselves, stem the tide of the opioid crisis is naïve and an oversimplification of the complex nature of the crisis.

Legitimate questions have been raised about whether some pain patients might now be undertreated, and whether tightened prescribing practices over the last few years has contributed to the surge in overdose deaths from heroin and especially fentanyl.

But the fact is that this crisis has been brewing for many years, fueled by a wide range of interrelated factors that cannot be considered in isolation.

The contributing factors (e.g.,

  • sheer numbers of painkillers in the market,
  • inadequate health care,
  • mismanagement of chronic pain conditions,
  • social angst, and
  • economic distress)

are all intimately connected and working interdependently. These factors must be addressed in a comprehensive, integrated, and strategic fashion if we want to see results.

advocating for the exploration of alternative pain management approaches must be accompanied by an equally potent advocacy for ensuring that opioids continue to be accessible, affordable, and covered by insurance for the patients for whom opioid medication might be the only available ones to control their pain.

  • There is a growing backlash among chronic pain patients and their advocates, who argue that public health reforms triggered by the opioid epidemic have now made it too hard for pain patients to get their medications. What is your view?

we shouldn’t be surprised if policies enacted in the heat of a devastating and protracted public health emergency fall victim to the “pendulum” effect.

Indeed, the typical risk of going too far in our otherwise “well intentioned” responses is the main reason why our policies should always be based on the best available evidence and attentive to the patients who depend on legitimate medically prescribed opioid use for chronic pain management.

We also believe that chronic pain patients should receive the best evidence-based care possible with a minimum of risk, which is why the HEAL Initiative also supports novel, less-addictive or non-addictive treatments for pain.

But there is no evidence for the effectiveness of alternative treatments. There is only evidence that they might be better than nothing at all, but no evidence they are as effective as opioids.

  • Human Rights Watch is reportedly doing a study on whether chronic pain patients’ human rights are now being violated because of the difficulty they encounter in obtaining opioid medications at the levels they used to.
    The group is reportedly focusing on the CDC Guidelines of 2016, and theorizes that insurers, state licensing authorities, and the DEA are interpreting the guidelines too rigidly, effectively barring prescriptions above 90 morphine milligram equivalents (MME) per day. Are you aware of excessively rigid interpretations in either the public or private sector?

HRW has the right to commission any study they deem appropriate. However, I certainly do not share their concerns about hidden agendas or the rigorous process that the CDC used for collecting, analyzing, and distilling the evidence that went into writing their latest guidance for the management of non-cancer chronic pain.

Wow, these problems with the guideline process are documented and easily available, so I’m surprised she claims not to know of them.

The problem, though, is that opioid tapering can be very challenging for both doctors and patients .

Existing opioid tapering models require interdisciplinary teams that are either very expensive or simply inaccessible to most patients (See here and here.)

As this TED talk suggests, too many chronic pain patients may be falling through the cracks of a system ill-designed to deal with the adverse effects of current pain management practice.

This is an important but larger health care policy issue that needs to be addressed as part of a comprehensive effort to combat the opioid crisis.

And before answering your last question, it is important to remember that, when treating patients on high doses of prescription opioids, a doctor must evaluate and support the patient’s mental health in the process.

Results of a recent study of high-risk veterans on chronic high-dose opioid therapy found that moderate-speed tapering can be achieved with support from mental health services and adequate follow-up and monitoring.

Now, there is some evidence to suggest that at least some patients who refuse tapering protocols may display increased levels of psychological inflexibility, characterized by

(a) a tendency to withdraw from valued activities and social participation in response to pain or its expectation and

(b) difficulty of distancing themselves from thoughts about the pain and its possible causes.

That’s right, blame problems with tapering on psychological problems instead of the resurgent pain.

These and associated traits may be amenable to specific behavioral or psychological targeting, such as exposure therapy, cognitive behavioral therapy (see here and here), acceptance and commitment therapy, or mindfulness.

Thus, a better understanding of a patient’s personality and how it might interact with their care could allow properly trained health care professionals to tailor not only the tapering protocol, but also their communication style in ways that make them more likely to be heard.

6 thoughts on “Nora Volkow on Rx opioids, chronic pain and ‘hype’

  1. Red Lawhern

    I logged the following comment on the site where Dr Volkow’s remarks are published:

    I suggest that there are several remarkable reversals in Nora Volkow’s comments, relative to a position which she and a co-author took in a paper for the New England Journal of Medicine:

    ““Unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opioids — even among those with pre-existing vulnerabilities… Older medical texts and several versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) either overemphasized the role of tolerance and physical dependence in the definition of addiction or equated these processes (DSM-III and DSM-IV). However, more recent studies have shown that the molecular mechanisms underlying addiction are distinct from those responsible for tolerance and physical dependence, in that they evolve much more slowly, last much longer, and disrupt multiple brain processes.”

    Nora D Volkow, MD and Thomas A McLellan, Ph.D., “Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies” . NEMJ 2016; 374:1253-1263 March 31, 2016].

    Moreover, I suggest that it has now been demonstrated beyond any reasonable contradiction that rates of opioid prescribing are completely unrelated to rates of opioid-related mortality from US State to State. This is true whether or not many addicts begin their addiction with exposure to opioids prescribed for someone else. The contribution of medically managed opioids to our overdose statistics is so small that it gets lost in the noise. I make this case in an article published June 21 in The Crime Report, titled “The Phony War Against Opioids – Some Inconvenient Truths”.

    Liked by 1 person

    1. Zyp Czyk Post author

      I blogged Dr. Volkov’s other article you mention:

      For those interested, here is also the link to your article in The Crime Report:

      Thank you for your comment – please feel free to post links to any other articles you deem pertinent.

      Liked by 1 person

  2. canarensis

    having a rough day, so I fear my comment is not going to be up to your excellent standards. In response to Volkow’s statement:
    “…at least some patients who refuse tapering protocols may display increased levels of psychological inflexibility, characterized by
    (a) a tendency to withdraw from valued activities and social participation in response to pain or its expectation and
    (b) difficulty of distancing themselves from thoughts about the pain and its possible causes. ”

    my reasoned & articulate response is, “AAAAAHHHHHHHHHHH!”

    Liked by 1 person

  3. Pingback: Nora Volkow on why opioids are unique | EDS and Chronic Pain News & Info

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